Initial public health response and interim clinical guidance for the 2019 novel coronavirus outbreak — United States, December 31, 2019–February 4, 2020

This article summarizes what is currently known about the 2019 novel coronavirus and offers interim guidance. This article summarizes what is currently known about the 2019 novel coronavirus and offers interim guidance. On December 31, 2019, Chinese health officials reported a cluster of cases of acute respiratory illness in persons associated with the Hunan seafood and animal market in the city of Wuhan, Hubei Province, in central China. On January 7, 2020, Chinese health officials confirmed that a novel coronavirus (2019-nCoV) was associated with this initial cluster.1World Health OrganizationNovel coronavirus (2019-nCoV). Situation report 1.. World Health Organization, Geneva, Switzerland2020Google Scholar As of February 4, 2020, a total of 20,471 confirmed cases, including 2,788 (13.6%) with severe illness,* and 425 deaths (2.1%) had been reported by the National Health Commission of China.2World Health OrganizationNovel coronavirus (2019-nCoV). Situation report 15. World Health Organization, Geneva, Switzerland2020Google Scholar Cases have also been reported in 26 locations outside of mainland China, including documentation of some person-to-person transmission and one death.2World Health OrganizationNovel coronavirus (2019-nCoV). Situation report 15. World Health Organization, Geneva, Switzerland2020Google Scholar As of February 4, 11 cases had been reported in the United States. On January 30, the World Health Organization (WHO) Director-General declared that the 2019-nCoV outbreak constitutes a Public Health Emergency of International Concern.† On January 31, the US Department of Health and Human Services (HHS) Secretary declared a US public health emergency to respond to 2019-nCoV.§ Also on January 31, the president of the United States signed a “Proclamation on Suspension of Entry as Immigrants and Nonimmigrants of Persons who Pose a Risk of Transmitting 2019 Novel Coronavirus,” which limits entry into the United States of persons who traveled to mainland China to US citizens and lawful permanent residents and their families.3Office of the PresidentProclamation on suspension of entry as immigrants and nonimmigrants of persons who pose a risk of transmitting 2019 novel coronavirus. Office of the President, Washington, DC2020Google Scholar CDC, multiple other federal agencies, state and local health departments, and other partners are implementing aggressive measures to slow transmission of 2019-nCoV in the United States.4Holloway R Rasmussen SA Zaza S Cox NJ Jernigan DB. Updated preparedness and response framework for influenza pandemics.MMWR Recomm Rep. 2014; 63Google Scholar,5Reed C Biggerstaff M Finelli L et al.Novel framework for assessing epidemiologic effects of influenza epidemics and pandemics.Emerg Infect Dis. 2013; 19: 85-91Crossref PubMed Scopus (82) Google Scholar These measures require the identification of cases and their contacts in the United States and the appropriate assessment and care of travelers arriving from mainland China to the United States. These measures are being implemented in anticipation of additional 2019-nCoV cases in the United States. Although these measures might not prevent the eventual establishment of ongoing, widespread transmission of the virus in the United States, they are being implemented to 1) slow the spread of illness; 2) provide time to better prepare health care systems and the general public to be ready if widespread transmission with substantial associated illness occurs; and 3) better characterize 2019-nCoV infection to guide public health recommendations and the development of medical countermeasures including diagnostics, therapeutics, and vaccines. Public health authorities are monitoring the situation closely. As more is learned about this novel virus and this outbreak, CDC will rapidly incorporate new knowledge into guidance for action by CDC and state and local health departments. Some coronaviruses, such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS), are the result of human-animal interactions. Preliminary investigation of 2019-nCoV also suggests a zoonotic origin,6Lu R, Zhao X, Li J, et al. Genomic characterization and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet 2020. Epub January 29, 2020.Google Scholar but the exact origin has not yet been determined. Person-to-person spread is evident;7Li Q, Guan X, Wu P, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus-infected pneumonia. N Engl J Med. 2020. Epub January 29, 2020.Google Scholar however, how easily the virus is transmitted between persons is currently unclear. 2019-nCoV is similar to coronaviruses that cause MERS and SARS, which are transmitted mainly by respiratory droplets. Signs and symptoms of patients with confirmed 2019-nCoV infection include fever, cough, and shortness of breath.8Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020. Epub January 30, 2020.Google Scholar Based on the incubation period of illness from MERS and SARS coronaviruses, CDC believes that symptoms of 2019-nCoV infection occur within 2 to 14 days following infection. Preliminary information suggests that older adults and persons with underlying health conditions or compromised immune systems might be at higher risk for severe illness from this virus9Hunag C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020. Epub January 24, 2020.Google Scholar; however, many characteristics of this novel coronavirus and how it might affect individual persons and potentially vulnerable population subgroups, such as the elderly or those with chronic health conditions, remain unclear. On January 21, 2020, the first person in the United States with diagnosed 2019-nCoV infection was reported. As of February 4, a total of 293 persons from 36 states, the District of Columbia, and the US Virgin Islands were under investigation based on current patient under investigation (PUI) definitions,¶ and also included those being evaluated because they are close contacts. Of these PUIs, 11 patients have confirmed 2019-nCoV infection using a real-time reverse transcription–polymerase chain reaction (RT-PCR) assay developed by CDC. These 11 cases were diagnosed in the following states: Arizona (one), California (six), Illinois (two), Massachusetts (one), and Washington (one) (Table 1). Nine cases were in travelers from Wuhan. Eight of these nine cases were identified as a result of patients seeking clinical care for symptoms and clinicians connecting with the appropriate public health systems. Two cases (one each in California and Illinois) occurred in close contacts of two confirmed cases and were diagnosed as part of routine monitoring of case contacts. All patients are being monitored closely for progressing illness. No deaths have been reported in the United States.TABLE 1Characteristics of initial 2019 novel coronavirus cases (N = 11) — United States, January 21–February 4, 2020CaseStateApproximate age (yrs)SexPlace of exposureDate laboratory confirmation announced1Washington30sMWuhan1/21/20202Illinois60sFWuhan1/24/20203Arizona20sMWuhan1/26/20204California30sMWuhan1/27/20205California50sMWuhan1/27/20206Illinois60sMHousehold Illinois1/30/20207California40sMWuhan1/31/20208Massachusetts20sMWuhan2/01/20209California50sFWuhan2/02/202010California50sMWuhan2/02/202011California50sFHousehold California2/02/2020Abbreviations: F, female; M, male. Open table in a new tab Abbreviations: F, female; M, male. CDC established a 2019-nCoV Incident Management Structure on January 7, 2020. On January 21, CDC activated its Emergency Operations Center to optimize coordination for domestic and international 2019-nCoV response efforts. To date, CDC has deployed teams to the US jurisdictions with cases to assist with epidemiologic investigation and to work closely with state and local partners to identify and monitor close contacts and better understand the spectrum of illness, transmission, and virulence associated with this novel virus. Information learned from these investigations will help inform response actions. CDC has closely monitored the global impact of this virus with staff members positioned in CDC offices around the world, including mainland China, and in coordination with other countries and WHO. This coordination has included deploying CDC staff members to work with WHO and providing active support to CDC offices in affected countries. In addition, CDC in response to the escalating risks of travel from China has issued a series of Travelers’ Health Notices for both Wuhan and the rest of China regarding the 2019-nCoV outbreak. On January 27, CDC issued a Level 3 travel notice for travelers to avoid all nonessential travel to mainland China.**** US quarantine stations, located at 18 major US ports of entry, are part of a comprehensive regulatory system authorized under section 361 of the Public Health Service Act (42 US Code Section 264), that limits the introduction of infectious diseases into the United States to prevent their spread. On January 17, consistent with existing communicable disease response protocols, CDC Quarantine staff members instituted enhanced entry screening of travelers on direct and connecting flights from Wuhan, China, arriving at three major US airports: Los Angeles (LAX), New York City (JFK), and San Francisco (SFO),†† which then expanded to include travelers arriving in Atlanta (ATL) and Chicago (ORD). These five airports together receive approximately 85% of all air travelers from Wuhan, China, to the United States. US Customs and Border Protection officers identified travelers arriving from Wuhan and referred them to CDC for health screening.§§ Any traveler from Wuhan with signs or symptoms of illness (eg, fever, cough, or difficulty breathing) received a more comprehensive public health assessment performed by CDC public health and medical officers.¶¶ All travelers from Wuhan were also provided CDC’s Travel Health Alert Notice (T-HAN)***** that advised them to monitor their health for 14 days and described recommended actions to take if relevant symptoms develop. As of February 1, 2020, a total of 3,099 persons on 437 flights were screened; five symptomatic travelers were referred by CDC to local health care providers for further medical evaluation, and one of these persons tested positive for 2019-nCoV.SummaryWhat is already known about this topic?In December 2019, an outbreak of acute respiratory illness caused by a novel coronavirus (2019-nCoV) was detected in mainland China. Cases have been reported in 26 additional locations, including the United States.What is added by this report?Nine of the first 11 US 2019-nCoV patients were exposed in Wuhan, China. CDC expects more US cases.What are the implications for public health practice?CDC, multiple other federal agencies, state and local health departments, and other partners are implementing aggressive measures to substantially slow US transmission of 2019-nCoV, including identification of US cases and contacts and managing travelers arriving from mainland China to the United States. Interim guidance is available at https://www.cdc.gov/coronavirus/index.html and will be updated as more information becomes available. What is already known about this topic? In December 2019, an outbreak of acute respiratory illness caused by a novel coronavirus (2019-nCoV) was detected in mainland China. Cases have been reported in 26 additional locations, including the United States. What is added by this report? Nine of the first 11 US 2019-nCoV patients were exposed in Wuhan, China. CDC expects more US cases. What are the implications for public health practice? CDC, multiple other federal agencies, state and local health departments, and other partners are implementing aggressive measures to substantially slow US transmission of 2019-nCoV, including identification of US cases and contacts and managing travelers arriving from mainland China to the United States. Interim guidance is available at https://www.cdc.gov/coronavirus/index.html and will be updated as more information becomes available. On January 24, 2020, travel bans began to be instituted by the Chinese government, resulting in restricted travel in and out of Hubei Province, including the city of Wuhan, and fewer travelers undergoing entry screening in the United States. In response to the escalating risks associated with travel from mainland China, on January 31, 2020, the Presidential Proclamation further refined the border health strategy to temporarily suspend entry, undergo additional screening, or possible quarantine for individuals that have visited China (excluding Hong Kong, Macau, and Taiwan) in the past 14 days. These enhanced entry screening efforts are taking place at 11 airports at which all air travelers from China are being directed. Chinese health officials posted the full 2019-nCoV genome sequence on January 10, 2020, to inform the development of specific diagnostic tests for this emergent coronavirus.1World Health OrganizationNovel coronavirus (2019-nCoV). Situation report 1.. World Health Organization, Geneva, Switzerland2020Google Scholar Within a week, CDC developed a Clinical Laboratory Improvement Amendments–approved real-time RT-PCR test that can diagnose 2019-nCoV respiratory samples from clinical specimens. On January 24, CDC publicly posted the assay protocol for this test (https://www.cdc.gov/coronavirus/2019-nCoV/lab/index.html). On January 4, 2020, the Food and Drug Administration issued an Emergency Use Authorization to enable emergency use of CDC’s 2019-nCoV Real-Time RT-PCR To date, this test has been to use at CDC This the use of the test at the CDC is closely with and public health including the Public Health to rapidly these tests and CDC’s International In addition, CDC the genome of the virus from the first reported cases in the United States to the National of Health sequence of publicly available CDC also is the virus in which is for further including for additional the virus will be available to assist efforts. information about 2019-nCoV is to better understand transmission, disease and risk to the general Although CDC and partners are about 2019-nCoV, initial CDC guidance is based on guidance for and of respiratory including and No or specific for 2019-nCoV infection is currently available. medical care for patients with 2019-nCoV is On January 31, CDC its Health with interim guidance for clinicians and public health In addition, CDC issued a Clinical Alert its and on January Interim guidance for health care is available at Health care providers identify patients who might have been exposed and who have signs or symptoms to 2019-nCoV these and inform public health departments. This a travel for patients being evaluated with and respiratory illness. to guide and of for 2019-nCoV include 1) or signs or symptoms of respiratory illness (eg, or shortness of in including health care who has had close with a patient with 2019-nCoV infection within 14 days of 2) and signs or symptoms of respiratory illness (eg, or shortness of in person with a of travel from Hubei Province, China, within 14 days of or 3) and signs or symptoms of respiratory illness (eg, or shortness of in person with a of travel from mainland China within 14 days of be tested based on with state and local public health for other possible of illness (eg, influenza and respiratory as CDC currently a to the of These patients be to a as as they are and to a if by at from other be evaluated in a with the an infection if available. 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Updated preparedness and response framework for influenza pandemics.MMWR Recomm Rep. 2014; 63Google Scholar,5Reed C Biggerstaff M Finelli L et al.Novel framework for assessing epidemiologic effects of influenza epidemics and pandemics.Emerg Infect Dis. 2013; 19: 85-91Crossref PubMed Scopus (82) Google Scholar These measures require the identification of cases and contacts in the United States and the of the travelers arriving from mainland China to the United States each of the PresidentProclamation on suspension of entry as immigrants and nonimmigrants of persons who pose a risk of transmitting 2019 novel coronavirus. Office of the President, Washington, DC2020Google Scholar These measures are being implemented based on the that will be more US 2019-nCoV cases with of transmission, with the that these measures might not prevent the eventual establishment of ongoing, widespread transmission of the virus in the United States. is for public health agencies, health care and the public to be of this new 2019-nCoV that and actions can help prevent additional cases or health that the US health care system in or US transmission of 2019-nCoV is already of the first 11 US cases were detected by clinicians with public health to test persons at of cases in the United States transmission risk and of the including its transmission and to inform and global response actions. 2019-nCoV symptoms are similar to those of influenza (eg, fever, cough, or and the outbreak is a time of respiratory from respiratory and other respiratory are To prevent all persons receive an influenza and is available and in to prevent Jernigan DB. and of influenza with recommendations of the on States, influenza Recomm Rep. 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Arizona Department of Health Department of Public California Department of Public Los Angeles Department of Public Health San Public Health Services Public Health Illinois Department of Public Chicago Department of Public Department of Public Health Massachusetts Department of Public Washington Department of Health All have and the International of for of of No of were of the respiratory or with or of within WHO. to guide and of patients under investigation for 2019-nCoV include 1) or signs or symptoms of respiratory illness (eg, or shortness of in including a health care who has had close with a patient with 2019-nCoV infection within 14 days of 2) and signs or symptoms of respiratory illness (eg, or shortness of in person with a of travel from Hubei Province, China, within 14 days of or 3) and signs or symptoms of respiratory illness (eg, or shortness of in person with a of travel from mainland China within 14 days of information is available at and CDC’s initial health screening a of each with a of these travelers for signs of respiratory illness (eg, or difficulty and of symptoms a more comprehensive public health assessment based on the illness and the traveler be to a for further medical and which might include for is as 1) being within approximately of a 2019-nCoV patient for a period not recommended (eg, National for and and close can occur or a health care or with a 2019-nCoV or 2) direct with infectious of a 2019-nCoV patient (eg, being not recommended